In the name of GOD Dysphagia - PowerPoint Presentation

Slide1

In the name of GOD

Slide2

Dysphagia

Slide3

Dysphagia is an

alarm

symptom that

warrants

prompt evaluation

to define the

exact

cause

and initiate

appropriate therapy.

Slide4

 It may be due to a structural or

motility

abnormality

in the passage of

solids

or

liquids

from the oral cavity to the

stomach

.

Slide5

Dysphagia

is a subjective sensation of

difficulty

or

abnormality of swallowing.

Odynophagia

is pain with swallowing.

Globus

sensation

is a

functional

esophageal disorder characterized by a sensation of a lump, tightness or retained food bolus in the pharyngeal or cervical area that

is not due to

an

underlying

structural

abnormality,

gastroesophageal

reflux disease

, or an esophageal

motility

disorder

.

Slide6

ACUTE

DYSPHAGIA:

 The acute onset of inability to swallow solids and/or liquids, including secretions, suggests

impaction

of a

foreign

body

in the esophagus and requires

immediate

attention

.

Food impaction is the most common cause

for acute onset of dysphagia in adults.

It has higher

incidence in

males

compared with females

.The

incidence increases with

age

, especially after the

seventh

decade.

Clinical presentation — Patients usually develop symptoms after ingesting

meat

(most commonly beef, chicken, and turkey), which completely obstructs the esophageal lumen, resulting in expectoration of saliva.

Management — The food bolus can be removed during upper

endoscopy

using grasping devices

,or

it can be gently pushed into the stomach

.

Slide7

EVALUATION OF NONACUTE

DYSPHAGIA:

Distinguishing

oropharyngeal

from esophageal dysphagia 

:

The

first step in evaluating patients with

nonacute

dysphagia is to determine if the symptoms are due to

oropharyngeal

or esophageal dysphagia based on the patient’s answers to the questions in the following

:

 

Slide8

Oropharyngeal dysphagia 

Oropharyngeal

or transfer dysphagia is characterized by these features:

●Patients have

difficulty

initiating

a swallow.

●Patients may point toward the

cervical region

as the site of their symptoms.

●Swallowing may be accompanied by

nasopharyngeal regurgitation

, aspiration, and a sensation of residual food remaining in the pharynx.

●Oral dysfunction can lead to

drooling

, food spillage,

sialorrhea

, piecemeal swallows, and

dysarthria

.

●Pharyngeal dysfunction can lead to

coughing

or choking during food consumption, and

dysphonia

.

Slide9

Esophageal dysphagia 

Patients with esophageal dysphagia commonly report the following:

●Difficulty swallowing

several seconds

after initiating a swallow, and

●A sensation that foods and/or liquids are being obstructed in their passage from the upper esophagus to the stomach.

Patients may point to the

suprasternal notch

or to an area behind the

sternum

as the site of obstruction.

Esophageal

dysphagia arises within the body of the esophagus, the lower esophageal sphincter, or

cardia

.

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Characterizing the symptomsSolid, liquid, or

both?

A

critical component of the medical history is determining the types of food that produce symptoms (

ie

, solids, liquids, or both). For example, dysphagia to

both

solids and liquids from the onset of symptoms is probably due to a

motility

disorder of the esophagus. Dysphagia to

solids

only is usually present when the esophageal lumen is narrowed to

13 mm

or less by a stricture.

Slide13

Progressive or

intermittent?

Progressive

dysphagia, beginning with dysphagia to solids followed by dysphagia to liquids, is usually caused by a peptic stricture or obstructing lesion

.

Symptoms of

peptic stricture

are

slowly

and gradually progressive, whereas those due to a

malignancy

progress more

rapidly

.

Intermittent

dysphagia may be related to a lower esophageal

ring

or

web

.

Patients

with

motility

disorders may also exhibit

progressive

dysphagia (

eg

,

achalasia

) or may exhibit

intermittent

or

nonprogressive

dysphagia (

eg

, distal esophageal

spasm

).

Slide14

Associated symptoms 

:

●Heartburn

●Weight loss

●Hematemesis

●Anemia

●Regurgitation of food particles, and

●Respiratory symptoms

As an example,

chronic heartburn

in a patient with dysphagia may be a clue to

complications

of

gastroesophageal

reflux

disease, such as

erosive esophagitis

,

peptic stricture

, or

adenocarcinoma

of the esophagus

.

Patients with peptic strictures usually have a history of heartburn and regurgitation but no weight loss, while patients with esophageal cancer tend to be older males with significant weight

loss.

Slide15

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APPROACH TO DIAGNOSTIC TESTING 

:

Pre-endoscopy

barium

esophagram

 

:

 

We

perform a 

barium

 contrast

esophagram

(barium swallow) as the 

initial test (prior to upper endoscopy)

in patients with the following:

●History/clinical features of proximal esophageal lesion (

eg

,

surgery

for laryngeal or esophageal cancer,

Zenker's

diverticulum, or

radiation

therapy).

●Known

complex

(tortuous)

stricture

(

eg

, post-caustic injury or radiation therapy)

.

Slide17

Upper endoscopy :

 Patients with

esophageal dysphagia

should be referred for an upper endoscopy to determine the underlying

cause

, exclude

malignancy

, and perform

therapy

(

eg

, dilation of an esophageal ring) if

needed.

Slide18

Post-endoscopy

barium

esophagram

 

:

 

We

obtain a 

barium

 

esophagram

after a negative upper endoscopy in patients in whom a mechanical obstruction is still suspected, as lower esophageal

rings

or

extrinsic

esophageal compression can be missed by an upper

endoscopy.

Slide19

Esophageal

manometry

 

:

 

Esophageal

manometry

should be performed in patients with dysphagia in whom upper

endoscopy

is unrevealing and/or an esophageal

motility

disorder is suspected

.

Although certain motility disorders (

eg

,

achalasia

) can be strongly suspected based upon their characteristic

radiographic

appearance when in advanced stages

,confirmation

with an esophageal

manometry

study is required to

establish

the

diagnosis.

Slide20

SYMPTOM-BASED DIFFERENTIAL DIAGNOSIS

Solids

only with progressive

symptoms:

Esophageal stricture

 — Dysphagia to solids that is only gradually progressive is suggestive of an esophageal stricture, which may be related to acid

reflux

,

radiation

therapy, or

eosinophilic

esophagus.

Peptic

stricture 

— Peptic stricture is a complication of

gastroesophageal

reflux disease (GERD) and results from the healing process of erosive esophagitis. This benign esophageal stricture is usually found in close proximity to the

esophagogastric

junction. The development of peptic strictures among patients with reflux has been associated with

older age

,

male

sex, and longer

duration

of reflux symptoms

.

Less common causes of stricture :

Caustic

ingestions,

Drug-induced

stricture.

Slide21

Carcinoma

 — Cancer of the esophagus or gastric

cardia

is associated with rapidly progressive dysphagia, initially for solids and later for liquids. In addition, patients may have chest pain, odynophagia, anemia, anorexia, and significant weight loss.

An

achalasia-like syndrome

(

pseudoachalasia

) has been described in patients with

adenocarcinoma

of the

cardia

due to microscopic infiltration of the

myenteric

plexus or the

vagus

nerve . Certain features increase the likelihood that a patient has

pseudoachalasia

due to malignancy include:

short duration

of symptoms (

ie

, less than

six

months

), presentation after

age 60

, excessive

weight

loss

in relation to the duration of symptoms, and

difficult

passage

of the

endoscope

through the

gastroesophageal

junction.

Slide22

Eosinophilic

esophagitis

 — Up to

15 percent

of patients being evaluated for dysphagia with endoscopy are found to have

eosinophilic

esophagitis

.

Endoscopic findings associated with

eosinophilic

esophagitis include:

●Stacked

circular rings

("feline" esophagus)

.

●

Strictures

(particularly proximal strictures)

.

●

Linear furrows

.

●

Whitish papules

(

representing eosinophil

microabscesses

).

●Small caliber esophagus

.

The

diagnosis of

eosinophilic

esophagitis is established by upper endoscopy and esophageal biopsy which demonstrates an increased number of

eosinophils

(>15 per high power field).

Slide23

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Esophageal webs and rings:

 

 Patients with esophageal rings and webs have

intermittent

dysphagia for

solids

. Esophageal rings have been described in association with iron deficiency (

ie

, the

Plummer-Vinson

or Patterson-Kelly syndrome) in which case anemia,

koilonychia

, or other manifestations of iron deficiency may be present. Esophageal webs and rings can partially or completely compromise the esophageal lumen .

They can be solitary or multiple.

●An

esophageal

web

is a

thin mucosal fold

that protrudes into the esophageal lumen and is covered with

squamous epithelium

.

Webs most commonly occur

anteriorly

in the

cervical

esophagus, causing focal narrowing in the

postcricoid

area .

●Esophageal

rings

are typically

mucosal

structures but in rare cases are

muscular

. Rings are found at the

gastroesophageal

junction

, are smooth,

thin

(<4 mm in axial length), and covered with

squamous mucosa

above and

columnar epithelium

below .

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Cardiovascular abnormalities

 

:

 Vascular anomalies can cause dysphagia by compressing the esophagus but are rare

.

Some of the aberrant vessels form

complete rings

, while others form

incomplete

rings

around the esophagus

.

●

Dysphagia

lusoria

is rare and is due to an aberrant right

subclavian

artery

that passes dorsally between the esophagus and the spine

.

●In older adults, severe

atherosclerosis

or a large

aneurysm

of the thoracic aorta can result in impingement on the esophagus and produce dysphagia ("

dysphagia

aortica

").

Extrinsic

compression of the esophagus may be noted on

barium

esophagram

, and the diagnosis can be established by

endoscopic

ultrasonography

or computed tomography (

CT

) scan.

If

symptoms are intractable, surgical intervention may be necessary.

Slide31

Liquid and/or solid dysphagia 

— Dysphagia to liquids alone or to solids and liquids may be related to either an

esophageal motility disorder

such as achalasia, distal esophageal spasm or

hypercontractile

esophagus or to a functional disorder

.

Other

motility disorders — If upper

endoscopy

with esophageal

biopsies

is normal in a patient with dysphagia to solids and/or liquids, further evaluation with

esophageal

manometry

 

and/or 

barium

 

esophagram

should be obtained.

Slide32

Achalasia 

—Achalasia is an uncommon disorder that can occur at

any age

, but is usually diagnosed in patients between 25 and 60 years.

Men and women

are affected with equal frequency.

Progressively

worsening dysphagia for solids (91 percent) and liquids (85 percent)

and regurgitation of bland, undigested food or saliva are the most frequent symptoms in patients with achalasia. Other symptoms include chest pain, heartburn, and difficulty belching.

Barium

 

esophagram

and upper

endoscopy

are complementary tests to

manometry

in the diagnosis of achalasia . Findings on barium

esophagram

that are suggestive of achalasia include a

dilated

esophagus that terminates in a

beak-like narrowing

(

ie

, ‘bird-beak’ appearance),

aperistalsis

, and poor emptying of barium from the esophagus . However,

barium

esophagram

may be

nondiagnostic

in up to one-third of patients .

Upper endoscopy is performed to exclude

pseudoachalasia

, and those patients without evidence of mechanical obstruction can then undergo esophageal

manometry

to confirm

the diagnosis. Lack of normal peristalsis in the distal two-thirds of the esophagus and incomplete LES relaxation on esophageal

manometry

are characteristic of achalasia.

Slide33

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Distal

esophageal spasm (DES)

and

hypercontractile

(

jackhammer

) esophagus can cause

intermittent

,

nonprogressive

dysphagia to

solids and liquids

.

Patients may also report associated

chest pain

.

In patients with DES, the barium

esophagram

may show

severe non-peristaltic contractions

, which may produce striking abnormalities in the barium column. These findings have resulted in descriptions such as "

r

os

ary

bead

" or "

corkscrew

" esophagus

.

However

, radiographic studies may be normal among patients with DES or be abnormal in patients with normal

manometry

testing; as a result, 

barium

 

esophagram

is

neither

sensitive

nor

specific

in this setting.

Slide36

Slide37

Slide38

●

Ineffective esophageal motility

:

 By high-resolution esophageal

manometry

, ineffective motility is defined as

greater than 50 percent of the liquid swallows being either weak or failed

. The

manometric

diagnosis of ineffective esophageal motility does not always correlate with symptoms or impaired esophageal function.

Absent

contractility

: 

High resolution

manometry

may demonstrate a

lack of esophageal body peristalsis

, which may be idiopathic or can be seen in patients with systemic disorders (

eg

, systemic sclerosis or mixed connected tissue syndrome). Absent contractility can lead to

persistent or intermittent dysphagia for both solids and liquids. 

Slide39

Systemic sclerosis (scleroderma) 

— Patients with systemic sclerosis often have a history of

heartburn

and

progressive

dysphagia to both solids and liquids secondary to the underlying motility abnormality or the presence of

peptic stricture

, which occurs in up to 50 percent of these patients

.

Endoscopy may

show erosive

esophagitis

or a

peptic stricture

resulting from acid

reflux.

Esophageal involvement is present in up to

90 percent

of patients with systemic sclerosis .

Scleroderma primarily involves the

smooth

muscle

layer of the gut wall, resulting in

atrophy and sclerosis

of the distal two-thirds of the esophagus

.

Absent peristalsis

(in the

distal two-thirds

of the esophagus) and poor bolus transit may be seen on esophageal

manometry

and impedance, and low or

absent

LES pressure

.

The proximal esophagus (striated muscle) is spared and exhibits normal motility. 

Slide40

Functional dysphagia

 

— According to the

Rome IV criteria

, functional dysphagia is defined by the following:

●

A

sense of solid and/or liquid food lodging

, sticking, or passing abnormally through the esophagus.

●No evidence that an esophageal mucosal or

structural abnormality

is the cause of the symptom.

●No evidence that

GERD or

eosinophilic

esophagitis

is the cause of the symptom.

●Absence of a major esophageal

motor disorder (

achalasia,

esophagogastric

junction outflow obstruction, distal esophageal spasm,

hypercontractile

esophagus, and absent peristalsis)

.

All

criteria must be fulfilled for the past

three months

with symptom onset at least

six months

prior to the diagnosis and with a frequency of at least once a week.

Symptoms

of dysphagia may be

intermittent

or present

after each meal

.

Patients

should be reassured and instructed to avoid

precipitating factors

and

chew

well

. In our experience, symptoms may improve with time. In patients with severe symptoms, despite these measures, a trial of a smooth muscle relaxant, such as a

calcium channel blocker or tricyclic antidepressant, can be offered

.

Empiric

dilation

with a mechanical (push-type or

Bougie

) dilator can be offered, but symptom response is variable

Slide41

Odynophagia and

dysphagia:

Infectious

esophagitis

 

— Patients with infectious esophagitis, especially due to

herpes simplex virus

, usually present with odynophagia and/

ordysphagia

.

Other causes of infectious esophagitis include

cytomegalovirus

and 

Candida

 species.

Candida

 species are the most common fungal cause of

esophagitis,.

Other pathogens, such as

mycobacteria

, occasionally cause esophagitis in

immunosuppressed

patients

.

Medication-induced esophagitis

 

— 

Symptoms

may include

dysphagia

,

odynophagia

, and/or 

retrosternal pain

. Patients often have a history of swallowing a pill

without

water

, commonly at

bedtime

.

Less

common causes

 

— Dysphagia and painful swallowing may be reported by patients with

reflux esophagitis

or esophageal

Crohn

disease

.

Slide42

OTHER CAUSES OF NONSPECIFIC DYSPHAGIA

Lymphocytic

esophagitis

 

— Lymphocytic esophagitis is characterized by the presence of a dense

peripapillary

lymphocytic

infiltrate

and

peripapillary

spongiosis

involving the

lower two-thirds

of the esophageal epithelium and the absence of significant

neutrophilic

or

eosinophilic

infiltrates

it

is unclear if it is a distinct clinical entity and its etiology is

unknown

.

Sjögren's

syndrome

 — Approximately

three-quarters of patients

with

Sjögren's

syndrome have associated dysphagia

.

Defective peristalsis

has been demonstrated in

one-third

or more of patients with primary

Sjögren's

syndrome

.

Xerostomia

appears to exacerbate swallowing discomfort but

does not

appear to

correlate

with dysphagia

.

Slide43

Thanks for your attention